Authors (including presenting author) :
Wu HHH(1), Lo WPJ(1), Wong CF(1), Yiu MC(1), Kwan HW(1), Chun YKE(1) & Ng CP(1)
Affiliation :
(1)Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
Keyword 1: :
Ventilator Standby Function
Keyword 2: :
Patient Safety Enhancement Programme
Keyword 3: :
Mechanical Ventilator safety
Keyword 4: :
Standard Operating Procedures (SOPs)
Keyword 5: :
Quality Improvement
Keyword 6: :
Intensive Care Unit
Introduction :
Standby function in mechanical ventilators is applied during initial setup confirmation or temporary suspension for clinical procedures, such as transport or intubation. However, failing to reactivate after reconnection can cause apnea, hypoxia, deterioration or even cardiac arrest, due to human errors and handover issues. Contributing factors include inexperienced staff, ineffective communication and emergencies. There were two reported incidents in Hong Kong, four in Japan and thirteen in the UK over three years. Effective prevention requires standardised operating practices, coordinated teamwork and multidisciplinary commitment.
Objectives :
This programme aimed to enhance patient safety by establishing clear Standard Operating Procedures (SOPs) for ventilator reactivation from standby function with target >95% compliance, promoting vigilance via dual-nurse verification of ventilator function after clinical events and strengthening staff competency via incident sharing, structural training, monitoring, and governance.
Methodology :
Implemented from September 2025, the programme included: 1. Development of SOPs on reactivation of ventilator from standby function defined prohibited standby conditions, outlined safe reactivation steps. After verifying the settings and functions, the ventilator was switched on to a test lung. Upon connecting to patient, the ventilator was paused with automatic resumption. Instant patient monitoring and documentation were mandatory.
2. Annual competency-based training and mandatory orientation for new staff were launched to assure 100% SOP compliance.
3. To ensure continuous alarm monitoring, the ventilator’s built-in etCO2 was deliberately avoided to prevent etCO2 function disablement if standby function is accidentally activated.
4. Regular audits of ventilator usage were conducted and incident reports addressed promptly with corrective actions.
5. Interactive collaboration with physiotherapists was to improve ventilator safety awareness and accountability.
Result & Outcome :
This programme fostered teamwork, professional accountability and a “speak-up” culture during the standby-related procedures. Audits showed 100% SOP adherence with no countable incidents. Spot awards and appreciation for preventing a potential standby portable ventilator error boosted staff morale. Overall, it bolstered patient safety, maintained momentum in safe ventilator use, promoted a positive professional culture and reinforced multidisciplinary roles in risk prevention.
